Vegetarian In Boston
Maynard S. Clark's Veggie and Boston Blog talks about vegetarian topics AND Boston-related topics, often intersecting them interestingly.
Maynard S. Clark is a long-time and well-known vegan in Greater Boston, who often quips in his 'elevator pitch':
"I've been vegan now for over half my natural life, longer than most human earthlings have been alive."

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Sunday, July 26, 2009

Forget Who Pays Medical Bills,It’s Who Sets the Cost(and it's not preventing any problems, anyway!)

WASHINGTON — Every fight over health care reform is different, and every fight over health care reform is the same.

In 1929, Michael Shadid, a doctor in western Oklahoma, proposed an idea for making medical care affordable to farmers. Rather than pay piecemeal for treatments, farmers would each contribute $50 a year to a cooperative. Dr. Shadid and his colleagues would pay their own salaries and expenses with the aggregate sum, and no farmer’s annual bill for family medical care would exceed $50.

Horrified by the plan, other Oklahoma doctors tried to revoke Dr. Shadid’s license. The conflict was soon duplicated across the country; cooperatives sprang up, and the American Medical Association tried to beat them back. The A.M.A.’s members, as the historian Paul Starr has written, felt threatened because the cooperatives “subjected doctors’ incomes and working conditions to direct control by their clients.”

The issue was clear: Who controls the doctor-patient relationship? That question has been at the core of every big subsequent battle over health care. Should doctors determine not only their patients’ treatment but also their own pay, through the fee-for-service system that has survived since the 1920s? Or should patients have more power in the relationship? And who could claim to act on patients’ behalf, monitoring treatments and bargaining with doctors?

Last week’s back and forth, when Congressional Democrats squabbled and Mr. Obama took his case to the public, highlighted how difficult his task will be. Reform of health care has the potential to threaten profits and incomes that make up one-sixth of the economy. More daunting, perhaps, Americans seem to have great trust in their doctors — more, certainly, than they trust the government on medical matters.

More than three in four Americans are “very satisfied” or “somewhat satisfied” with their own care, according to the latest New York Times/CBS News poll. But a substantial majority also say that the health care system needs fundamental change and that rising costs are a serious threat to the economy — a view that economists strongly share.

Thus the political challenge facing any effort at an overhaul: Americans say they want change, but they also want to preserve their own status quo.

The disconnect can be explained partly by the peculiar economics of health care. Because third parties — the government or a private insurer — typically pay the bill, many people miss the fact that the money originally comes from them. They see the benefits of medical care without seeing the costs.

But trust in doctors is a factor as well. Even when doctors order costly treatments with serious side effects and little evidence of their being effective, as studies find is common, patients are loath to question the decision. Instead of blaming such treatments for the rising cost of medicine, many people are inclined to blame forces that health economists say are far less important, like greedy insurance companies or onerous malpractice laws.

Mr. Obama is well aware of the public perception. This is why he directs his criticism not at doctors but at insurers and drug companies. In his news conference on Wednesday night, he advocated creating a government panel with the power to begin moving Medicare away from its fee-for-service model and emphasize outcomes instead. But he described it in doctor-friendly terms — as “an independent group of doctors and medical experts who are empowered to eliminate waste and inefficiency.”

His rhetorical choices highlight one of the least discussed but most important conflicts in the current health care debate. The fight isn’t just a matter of Democrats vs. Republicans, Blue Dogs vs. liberals or patients vs. insurers. It is also doctors vs. doctors.

That’s the same as in Oklahoma in 1929. And what has happened to Dr. Shadid’s model? It has survived. He built a team of doctors who collaborated closely and were not paid based on how many procedures they performed. Today, this description fits the Mayo Clinic and the Cleveland Clinic (which Mr. Obama visited on Thursday), as well as less-known groups around the country.

Medicare data shows that these groups generally provide less expensive care and appear to deliver better results. Armed with this data, the doctors who run the groups have been lobbying Congress to make their model a bigger part of health reform. Two weeks ago, 13 such groups released a letter saying that recent versions of proposed legislation did not control costs enough.

Their goal is to weaken the fee-for-service system. In its place, doctors might receive a lump-sum payment to treat a patient with a certain condition, based on average costs elsewhere and on what scientific evidence had found to be effective. Hospitals with especially good outcomes might earn bonuses.

Advocates say such a system could ultimately give doctors more control. Rather than having to organize their schedules around the tests and procedures that insurers agree to reimburse, doctors could opt for the treatments they deem most effective. “It’s a lot more accountability, which is why it’s scary for physicians,” said Dr. Mark McClellan, a former head of Medicare under George W. Bush. “But in some ways it’s also more autonomy.”

On Tuesday, doctors and hospital executives from 10 cities with below-average cost growth gathered in Washington for a conference called, “How Do They Do That?” They were a diverse lot, only some of whom hailed from providers resembling the Mayo Clinic. While crediting a range of factors for their success, they generally agreed about what ails American medicine.

When Dr. McClellan, who helped organize the conference, asked how many people thought the fee-for-service system was “archaic and fundamentally at odds” with good practice, most hands shot up. In effect, they were siding with Dr. Shadid and against a system that provides incentives for more and more care, regardless of its benefit.

“There are no consequences right now to over-utilization,” Dr. Anthony F. Oliva, chief medical officer of the Guthrie Healthcare System, in northeast Pennsylvania, said later. “If you don’t have consequences, you won’t change the culture. If you don’t have consequences, the people that are killing themselves to control cost are going to say, ‘Why am I doing this?’”

It is a message, of course, that a doctor can deliver more easily than anyone else.

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About Me

In past three years, I completed REACH Intermediate (Harvard), Research Administration (Emmanuel College RAC/GCRA), NIH rDNA, and RTP (HSPH) Certificates. Completing Capstone research and thesis after two years of graduate courses for Master of Science in Management (MSM in Research Administration) in Boston's Emmanuel College. Have been working at Harvard for a VERY long time - there's SO much here!

I've been vegan over half my life. That's longer than most human earthlings (and most NONHUMAN earthlings) have been alive. All that time, I've been making connections for plant-based diets - and doing that through the Vegetarian Resource Center since 1993 (and before that through various strategies and structures.

My observation is that the vegan *movement* is constituted by fellow humans who have awakened to moral sensitivity in our individual observations of the populated world around us, a world that filled plentifully with persons - not only human, but also nonhuman, and that all persons are such that moral consideration is due to all of them. We cannot give that consideration individually; therefore, we must become persons of principle, who resolve our ethical duties towards other persons at a level of principle and self-regulation. I believe in 'ahimsa' or 'dynamic injury' as the proper regulatory principle for human behavior.

I also believe that many practicing vegans have attached nonessentials to being vegan, which often are their political aspirations and their willingness to 'entitle' certain kinds of activity 'over against' things that they wish to reduce with the same energy with which they are holding out their idea of what veganism is. I think that the idea of veganism is independent of that, tht it is defined BY (a) purely plant-based diets without the inclusion of honey or anything from animal or insect and (b) a principle of non-injury that is grounded in one's sense of the moral considerableness of personhood, regardless of how those persons act. One's ability to recognize those claims in any particular case are abetted or abated by the context in which those others are experienced and how they impact us. At the least, we have, I think as a vegan for ethical reasons, a duty to not cause needless harm to others, and those needless harms in mid-2014 would be harms for our clothing, food, shelter, medicinal ingredients, entertainment, etc.

Where there are challenges to living by those principles, we need, I believe as an ethical vegan, to agitate and organize for effective means to realize optimal ways to realize those values in the material world where we find ourselves.